The Welsh NHS Confederation Response to the Guidance in relation to Part 9 of the Act on Cooperation

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1 Purpose: The Welsh NHS Confederation Response to the Guidance in relation to Part 9 of the Act on Cooperation and Partnership. Contact: Nesta Lloyd Jones, Policy and Public Affairs Officer, the Welsh NHS Confederation. Nesta.lloyd-jones@welshconfed.org Tel: Date created: 31 July Introduction The Welsh NHS Confederation, on behalf of its members, welcomes the opportunity to respond to the Guidance in relation to Part 9 of the Act on Co-operation and Partnership consultation. We are committed to working in partnership with our social care partners and other public bodies. By representing the seven Health Boards and three NHS Trusts in Wales, the Welsh NHS Confederation brings together the full range of organisations that make up the modern NHS in Wales. Our aim is to reflect the different perspectives as well as the common views of the organisations we represent. The Welsh NHS Confederation supports our members to improve health and well-being by working with them to deliver high standards of care for patients and best value for taxpayers money. We act as a driving force for positive change through strong representation and our policy, influencing and engagement work. Members involvement underpins all our various activities and we are pleased to have all Local Health Boards and NHS Trusts in Wales as our members. The Welsh NHS Confederation and its members are committed to working with the Welsh Government and its partners to ensure there is a strong NHS which delivers high quality services to the people of Wales. Summary The NHS in Wales is committed to working in partnership with social care and other public bodies. For a long time Wales has recognised the vital link between health and social care. Strong social services are key if the health service is to be in a position to deliver the best for its patients and their families. The collaborative work that has been taking place between the health and social care sectors has dramatically helped the NHS at a time when the system is coming under pressure from a combination of increased demand and costs pressures. Some of these challenges are unprecedented for our health system, and are expected to grow in coming years. Therefore social services will continue to play a significant role if we are to be successful in building a health and social care system that is fit for the future needs of the population. Our members are keenly aware of the need for whole system change in public services. Collaborative working gives us the best chance to make sure there are positive outcomes for patients and a reduction in health inequalities as well as helping people avoid hospital admissions and receive care within their own communities. To achieve these outcomes it is vital that health is not seen as a standalone issue that is solely the responsibility of the NHS and that integration is prioritised. Integration is not just about health and social care. It is much wider than this and all sectors must recognise their responsibility in ensuring the health and well-being of the people of Wales. We need to engage with all our public service colleagues, from social care to housing, education and transport, to take us all from an ill-health service that puts unnecessary pressure on hospital services, to one that promotes healthy lives. All public bodies in Wales must work together and we, in turn, must support our partners and colleagues in other sectors. 1

2 Cooperation & Partnership 1. Do you agree with the proposed membership of the regional partnership boards? Tend to agree Please provide additional information as necessary to support your response suggesting any changes or additions to the proposed membership. We welcome the emphasis on cooperation and partnership as it is recognised that, despite its title, the Act cannot be delivered by social services in isolation. The NHS in Wales is committed to making its contribution to meeting the purpose of Part 9 of the Act. This will ensure that the Local Authorities, Health Boards, NHS Trusts and other partners work effectively together to plan and deliver integrated services, care and support that best meets the needs of people in their local area. Many Health Boards in Wales have a strong history of partnership working with their Local Authorities, third sector and other stakeholders. In Cwm Taf University Health Board the work conducted by the Regional Collaboration Board (joint Local Service Board across Rhondda Cynon Taf and Merthyr) was highlighted as good practice in the consultation on the Well-being of Future Generations Bill and this will support Cwm Taf University Health Board to work across the footprint to deliver the Social Services and Well-being Act. In Cwm Taf they have already established their Regional Social Services and Well-being Partnership Board and an Executive Leadership group reporting to it. The draft statutory guidance provides further information and clarity around the membership, role, requirements of the Regional Partnership Board and the issues Cwm Taf will need to consider in ensuring their structures are fit for purpose and deliver effectively. However, it will be important that the Guidance is not overly prescriptive as arrangements will vary across Wales and the infrastructure required to deliver the integration agenda will vary depending on what is already in place locally and the maturity of existing partnership arrangements. In relation to the proposed Regional Partnership Boards we have a couple of comments to make. Firstly, given the emphasis on working together to determine where the integrated provision of services, care and support is provided to improve people s outcomes and well-being, we recommend that consideration is given to include representation from relevant Directors of Public Health, or their nominated representatives, on the Regional Partnership Boards. As the Regional Partnership Boards have a remit for adults and children s services, Regional Boards should be guided to have balanced membership within their governance structures to reflect this. Secondly, we do not believe it is appropriate to have a single Mid and West Regional Partnership Board spanning both Hywel Dda University Health Board and Powys teaching Health Board because of the size and differing agendas and structures of each Health Board. A separate regional board for West Wales and Mid Wales would better facilitate effective integration and partnership working on each individual population footprint. The existing governance arrangements for the Mid and West Wales Health and Social Care Collaborative could provide the mechanisms for cross-regional dialogue on common issues and challenges. Thirdly the inter-relationships between neighbouring Regional Partnerships Boards is vital to avoid duplication and ensure consistency, for example North Wales Regional Partnership Board and other partnerships such as the Mid and West Wales Health and Social Care Collaborative. This will help ensure that the Health Boards meets their responsibilities to receive assurances with regard to the systems of control in place (clinical and non clinical), and form a view on their reliability, robustness, integrity and comprehensiveness, based on the information provided. This extends not only to the Health Board s own arrangements, but to work undertaken through partnerships, shared services and other inter-organisational work. Therefore a governance framework, setting out lead responsibilities, 2

3 representation, information flows, risk management, performance measures will be required when testing the reporting arrangements through appropriate organisational structures. Fourthly, there is reference in the Regulations to the Regional Partnership Boards ensuring that partners work effectively to implement the health and well-being strategies required by section 40 of the NHS Wales Act It is our understanding that this section has been repealed as part of the Well-being of Future Generations Act 2015 (Schedule 4 para 19). Local Health Boards no longer have Health, Social Care and Wellbeing Strategies as originally put in place under this section of the NHS Wales Act It would be helpful to clarify the reference as the Well-being Plans required by the Well-being of Future Generations Act 2015 will be the responsibility of the new Public Service Boards and not the Social Services and Well-being Partnerships. This plan will cover a wider range of issues affecting the general population compared with the requirements of the Social Services and Wellbeing Act in relation to care and support and preventative services. Fifthly, while the Welsh Ambulance Service NHS Trust (WAST) would not expect to be part of the required membership of the Regional Partnership Boards, partnership working is important to WAST. It important that due regard is given to the role WAST can play in delivering health outcomes and that they are appropriately involved when required by the Regional Partnership Boards. Finally, the role of the Third Sector in delivering the requirements of the Social Services and Well-being Act and the added value they can offer will be significant. While it is recognised that duties cannot be placed on the third sector in the same way as the other statutory bodies, their accountability and governance arrangements will still need to be addressed and there is little reference to the third sector in the draft Guidance. We recognise the potential value of appropriate independent sector representation on the Regional Partnership Boards, but would look for appropriate arrangements to be in place to manage potential conflict of interest or commercial sensitivities in discussions around commissioning and market sustainability. It is also vital to secure representation from a range of third sector organisations because of the breadth of expertise and knowledge the third sector has. 2. Do you agree with the proposals for pooled funds? Tend to Agree Please specify if there are any other areas that should be considered, highlighting the one key priority area. We agree with the principle of pooling funds to support care in the sector. However, determining the pooled fund can be difficult. Local Authorities and Health Boards are large organisations and have very different functions and governance structures, therefore pooled funds need to be considered carefully. Pooled funds should be prioritised by public bodies and must be sustainable. There are some other areas that should be considered. Firstly the Regulations and statutory guidance require pooled funds in relation to care home accommodation functions and family support functions. While recognising the Welsh Government s desire to promote the greater use of such arrangements and funds, the difficulties, complexities and staff/technical capacity to address and meet all the requirements must not be overlooked or underestimated, particularly in relation to care homes. Legal challenges and issues are already causing uncertainty and partners may be unable to proceed with joint arrangements until some of this is clarified and resolved. The draft Guidance states it will be important for Local Authorities and Health Boards to identify which functions or services would improve the effectiveness of integration by the direct payment or a pooled fund it is our view that it would be more helpful for the Regional Partnership Boards to determine the areas for 3

4 pooled budgets rather than the prescriptive approach adopted in the Guidance. Pooled budgets should be a means to an end, not the end in itself which appears to be the case in the Guidance. Secondly, the section on pooled funds for the Integrated Family Support Service would benefit from being more clearly articulated. The Integrated Family Support Service was previously funded by Welsh Government as a grant to each region, but since April 1 st, 2015 grant funding has been transferred into each Local Authorities annual settlement (Revenue Support Grant). Paragraph 2, page 15, of the Statutory Guidance on Partnership Arrangements could be misleading because its states...funding is allocated to local authorities as part of the annual settlement. In paragraph 3 it then goes on to say that partners can contribute to a pooled fund. The transfer of the grant in April 2015 was intended to provide financial resources to cover the costs of health and social care posts. From a Health Board s perspective it is important that this precedent is not overlooked as Health Boards have no core budget to fund the Integrated Family Support Service. If the funding allocation was further reduced then there would be an impact on the continuation of service provision as this could result in the post being decommissioned and or reduced hours for the staff concerned. This in turn could affect the ethos of service model delivery trying to be achieved through the Social Services and Well-being Act. Finally, page 6 of the Consultation document states that the regulation making powers will be used to ensure appropriate structures and resources are in place to enable the provision of integrated services to respond effectively to the joint population assessment. It is not clear how the powers referred to can ensure availability of resource, particularly at a time of significant financial challenge and austerity. 3. Do you agree with the priority areas identified for regional partnership boards: Older people with complex needs and long term conditions. Integrated Family Support Services. Learning disabilities. Children with complex needs due to disability or illness. Carers. Tend to agree Please specify if there are any other areas that should be considered, highlighting the one key priority area. The draft statutory guidance states that the Regional Partnership Boards will need to prioritise the integration of services in relation to a number of specified client groups. While it also allows for Regional Partnership Boards to determine other priority areas locally, we would advocate for flexibility rather than prescription in relation to priority areas as these will inevitably change over time and local circumstances will need to inform prioritisation of activity. If the guidance is prescriptive, we recommend that the other areas that should be identified as priorities for Regional Partnership Boards include: - Mental health; Mental Health Services are an ever increasing need e.g. increased incidence of depression and associated illnesses and the support required for these individuals. - Substance misuse - Adoption We feel that the priorities should also include people with complex needs due to sensory and physical disability irrespective of age. These key groups (many of whom are working age, with a neurological condition) often do not have access to well-coordinated services and could also benefit greatly from having a partnership focus. 4

5 There is a risk that services which encompass groups which are both prioritised and not prioritised for integration may be adversely affected (for example a community service which sees all ages of people with complex needs and long term conditions), whereas the Guidance prioritises older people in this category. This would be complicated in practice and could potentially shift resources based on age. 4. Do you agree with the proposals in relation to integrated family support services? Agree Please explain why. Overall we agree with the proposals in relation to integrated family support services but would recommend that some amendments are made to the Statutory Guidance on Partnership Arrangements. Page 9, paragraph 4 of the Statutory Guidance on Partnership Arrangements states: The Regulations also require the establishment of Integrated Family Support Teams. We would suggest the following wording to be added: Local Authorities have been allocated funding as part of the local settlement to enable integrated family support services to be established and to cover the health and social care costs of the service. Page 10, para 4 of the Statutory Guidance on Partnership Arrangements states: An integrated family support team must contain staff with suitable skills and experience.... It is suggested that this paragraph should be expanded as follows: An integrated family support team must contain staff with suitable skills and experience, including at least one consultant social worker, social work qualified professional and registered health professional, having regard to.... Additionally we consider that a mental health trained professional is an essential component of the team that brings a high level skill set and we would like to see that this is also reflected within this particular paragraph. Page 11, paragraph 1 of the Statutory Guidance on Partnership Arrangements again refers to the responsibility of Health Boards to participate in the establishment of the integrated family support services. Without the clarification that the current financial resources are sitting in the Local Authority s local settlement this could be read as the Health Board is expected to contribute additional financial / staff resources to a pooled budget. Page 13, para 2 of the Statutory Guidance on Partnership Arrangements says that the pooled fund for integrated family support services will be at a regional / consortium level rather than an individual Local Authority level. At present the funding is allocated to each individual Local Authority Revenue Support Grant and it has not been pooled since the change in funding mechanisms introduced on April 1 st, This paragraph suggests a different approach but this could only be achieved if Welsh Government directs Local Authorities to pool the funding which has been delegated to them. In addition, each Local Authority currently operates its own local area integrated family support services. The proposals in this document may require a review of integrated family support services delivery arrangements in future. It is our members view that without adequate financial resources there may need to be a review of the delivery of the model presently established, for example move from 3 teams to a centralised team outreaching to 3 counties which will impact on the number of cases. Finally, in relation to integrated family support services it is important that the Act provides increased protection to people experiencing domestic abuse. The reporting of domestic abuse is increasing and those experiencing domestic abuse, especially vulnerable children and older adults, need to be protected and supported by a number of agencies. 5

6 5. Do you agree the proposals will lead to improved outcomes for people and make more effective use of resources? Agree Please set out where further action should be taken. Overall we do agree that the proposals will lead to improved outcomes for people and make more effective use of resources. The expectation that there will be a written agreement to underpin partnership arrangements which involve the delegation of functions or the operation of multi-disciplinary, multi-agency teams should ensure the most effective use of resources to achieve the positive outcomes required and enable more successful and consistent prioritisation. Support and expertise to enable the technical aspects of partnership arrangements and pooled funds may be helpful to enable the process and reduce duplication of effort. While we agree that partnership working, integration and pooled budgets are a step in the right direction, in themselves they will not automatically lead to improved outcomes and a more effective use of resources. The work of the Regional Partnership Boards need to be supported by a focus on the systems (rather than functional or organisational lines) through which service users interact with organisations (public, private and voluntary). There needs to be clarity about the purpose of each system and the measures of success for each system, in particular the outcome measures. It should also be recognised that partnership working and integration is already happening through professional relationships across agencies so there are questions to raise about how much tangible difference the Act will make. Improved outcomes for people and effective use of resources will ultimately depend on how well practitioners from different organisations work together with people, which is influenced by organisational culture (trust, transparency, understanding and valuing of roles), communication and shared priorities. There will also be some implementation challenges particularly where priorities for Health Boards and Local Authorities do not necessarily align, for example the stroke delivery pathway is a priority for NHS Wales but not for Local Authorities partners and can impact on what is delivered with regard to life after a stroke. Other The Welsh Government is interested in understanding whether the proposals in this consultation document regarding part 9 will have an impact on groups with protected characteristics. Protected characteristics are: age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion and belief, sex, and sexual orientation. 6. Do you think that the proposals in this consultation will have any positive impacts on groups with protected characteristics? If so, which and why/why not? Yes, in principle the proposals should have a positive impact. However it is difficult to assess this at this stage and we would expect any service changes as a result of the work of the Regional Partnership Boards to be subject to an equality impact assessments. The provision of an integrated service should mean the response will be a multi-agency assessment. 6

7 7. Do you think that the proposals in this consultation will have any negative impacts on groups with protected characteristics? If so, which and why/why not? As per our answer to 6 we would expect any service change to be subject to an equalities impact assessment so that any potential negative impacts are identified and appropriate action taken. 8. Re-balancing the care and support system to deliver the new legal framework will require reprioritisation of resources. What are the key actions that need to be taken to achieve this? There are a number of key actions that need to be taken to re-balance the care and support system to deliver the new legal framework. Some actions that need to be taken include; Ensuring that when any assessment is undertaken the safeguarding element is integral to the assessment. Clear identification and understanding on how the key cross functional/ organisational systems will impact on people using the service. It is important to consider the new system is considered from a service user perspective to ensure that there is clarity as to the purpose of these systems and the outcomes that we are trying to achieve. While pooling resources maybe key, organisations will need to be open and transparent when sharing information. IT systems will need to communicate with each other and be consistent. There will need to be a standard data set and priorities and outcomes will need to be the same for the NHS, Local Authorities and others in relation to this aspect of health and social care delivery. Alignment of priorities and performance reporting across organisations would be required. 9. We have asked a number of specific questions. If you have any related issues which we have not specifically addressed, please use this space to tell us about them. Delivering Transformation As highlighted previously it should be recognised that partnership working and integration is already happening across health and social care. The Welsh NHS Confederation has been working closely with ADSS Cymru on Delivering Transformation project, previously Strengthening the Connections, to take the practical steps required for the integration of health and social care services. As part of the project a Collaborative Agreement was created between the Welsh NHS Confederation and ADSS Cymru in support of the Social Services & Well-being (Wales) Act The Agreement involves the participation of the Wales Council for Voluntary Action (WCVA), Care Forum Wales (CFW), the Wales Local Government Association (WLGA) and Community Housing Cymru (CHC). The Agreement allows for the sharing of a collective responsibility and the promotion of consistency regionally, locally and nationally. It facilitates mature relationships and the modelling of constructive and collaborative behaviour that is expected of other service providers. It also allows for the promotion of quality services through the development and maintenance of a skilled and confident workforce. In the lead up to the implementation of the Social Services and Well-being Act in April 2016 the project has developed a self-assessment tool to help regions assess their readiness to comply with the duties of the Act. The tool gives providers the opportunity to judge how ready services are to implement the duties and responsibilities of the Act. The tool is intended to support the development of regional implementation plans. 7

8 In addition a National Framework is being developed and informed by conservations that took place when creating the self-assessment tool. The objective of the Framework is to support the development of consistent and complementary regional implementation plans. Finally a National Work Programme will be produced focusing on five priority areas. The areas include; Safeguarding This is a shared priority between Local Government, NHS Wales and social services. It has resonance in light of the 'Trusted to Care' report, other incidents elsewhere and the impact of the Review of Residential Care by the Older People's Commissioner. Workforce - The Social Services and Well-being Act requires a considerable shift in practice, giving people a real voice and moving away from asking ' what can we do for you?' to asking 'can you help me understand what will make a difference to your life?' This patient focus ties in with prudent healthcare, putting the individual needs of people at the heart of service delivery. Integration - We will continue to promote shared learning and modelling the behaviour that aids collaboration and integration. Working with the other signatories it will be important to support best regional practice, in order that others can learn from it. Commissioning - This is critical as it allows the NHS and Local Government to think and plan together about the services that need to be in place over the next 10 years. Citizen directed approach and a stronger voice for citizens - In delivering health and social care services closer to people's homes and encouraging people to take more responsibility for their health and well-being, a different approach is required from NHS Wales and Local Government. Each of these priorities has a Social Services lead complemented by a Health Board Director. This enables the sharing of responsibility for the implementation of the SSWB Act and the development of the work programme. Local Government re-organisation In relation to Local Government reforms, the Welsh NHS Confederation, on behalf of its members, has engaged significantly with the proposed changes. We welcomed the publication of the Williams Commission report and we responded to its recommendations, highlighting that we recognised that they have the potential to support better integration and reduce overall demands on health, and drive improvements across the board. However, to date, Local Government re-organisation has dominated the debate and potentially it is a missed opportunity to support better integration between all public bodies in Wales. The debate since the Williams report and the Welsh Government response focuses too much on structures and boundaries and not on the outcomes it is trying to achieve; improving the way all public services are governed and delivered in Wales. The Williams Commission recommended that Urgent action is required to ensure that seamless, integrated and high-quality health and social services are provided across Wales. In commenting on the recommendations within the Williams report we recognised that they have the potential to support better integration and reduce overall demands on health, and drive improvements across the board. The potential reduction in the numbers of Local Authorities should aid multi-agency working. Working with fewer Local Authorities will streamline the integration process for Health Boards, and there will be fewer structural barriers to collaborative working across the board. However to enable Local Health Boards and Local Government to work well it is important that their boundaries are coterminous, especially for primary, community and social care. With the introduction of the Social Services and Well-being Act and the Well-being of Future Generations Act it is important, with the Public Services Boards and local well-being plans being placed on a statutory basis, that Local Authorities and Health Boards are conterminous and the boundaries aligned. 8

9 Governance We agree with the Statutory Guidance on Partnership Arrangements statement that it is essential that effective governance and accountability arrangements are in place. To mitigate risk it may be helpful to have agreed principles, or perhaps template agreements, to drive a level of consistency and share good practice across Wales. Welsh Ambulance Services NHS Trust WAST is supportive of the integration of health and social care and the partnership working needed to achieve this. When it comes to integration between health and social care WAST has a particular interest in the management of frequent callers (individuals and residential care settings) as a way of managing demand and improving the care service users receive. WAST is also interested in increased partnership working to help with alternative care pathways to ensure the best option for service users and to better manage demand in the ambulance care pathway. Improved partnership working around directories of services is an area that WAST is keen to develop further. WAST will also need to give further regard to partnership working within the NHS Direct Wales service and proposed 111 service. Conclusion While collaboration across sectors may not always be easy and requires hard work and determination, if the ambition and will is there it can be done. There are many examples in Wales where working across sectors is bringing about benefits for both the organisations that are involved and those that use or rely on the services. As we move forward we must strengthen these partnerships and continue to seek and develop new ways of working. Through the Social Services and Well-being Act and by increasing the levels of integration in Wales we will provide the right care for people, reduce pressure on the health service and empower people to take responsibility for their own health and well-being. 9